Homebirth: Tradition into Law

[imgbelt img=loveness528.jpg]With advances in midwifery and a growing culture of self-determination, more women are choosing to give birth at home. Homebirth advocaters are asking how (or whether) law should address the threshold of life.

Eli held baby sister Hazel after a home birth in Pike County, KY, November 2012. Home birthing advocates pressed for a state law to license midwives and create a board to oversee midwifery practice, but the bill never came to a vote. Home births are still prohibited in Kentucky.

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31 states showed statistically significant increases in the rate of women choosing to give birth at home. And in eight states – Montana, Oregon, Vermont, Idaho, Washington, Utah, Wisconsin, and Pennsylvania — the home birth rate rose to 1.5% or higher.

According to the CDC, “In 2009, there were 29,650 home births in the United States (representing 0.72% of births), the highest level since data on this item began to be collected in 1989.”

As birth practices are changing, however, the health laws in many states have yet to catch up, a hardship and in some instances a criminal risk for women who choose home birth and the midwives who assist them.

The overwhelming majority of homebirths in the United States are planned homebirths and are attended by various trained birth professionals, most of whom use term “midwife” for themselves. Currently, 27 states have some form of legislation in place to legalize, license, or regulate the practitioners of homebirth midwifery. In 10 states, the practice of homebirth midwifery is outright prohibited by statute, judicial interpretation, or stricture of practice.

Kentucky is one of these states that prohibit homebirths, even as homebirth rates in Kentucky increased 26.7% between 2004 and 2009.

During the 2013 legislative session, a grassroots organization called the Kentucky Homebirth Coalition (KHBC) joined with similar organizations in states nationwide and found support to introduce a bill that would license direct-entry midwives under the Certified Professional Midwife (CPM) credential. (A direct-entry midwife is an independent practitioner educated “through self-study, apprenticeship, a midwifery school, or a college- or university-based program distinct from the discipline of nursing.”)

The proposed bill would also create a Board of Midwifery in Kentucky to oversee the licensing of practicioners. The bill made its way to the state’s Health and Welfare Committee but did not receive a hearing during this legislative session.

Currently, because the state does not issue licenses to homebirth midwives, Kentucky – through omission — makes it illegal for direct-entry midwives to attend births in the homes of the families that choose them for their care. With each birth Kentucky midwives attend, they face the possibility of prosecution under various offenses, both misdemeanor and felony.

British Medical Journal (2005) found that not only is homebirth for low-risk women comparable to low-risk hospital births for the neonate, the risk to the mother is lessened due to lower rates of medical intervention.

Cristin Stanley-Potter described how her options for childbirthing are limited, adding that access even to those limited options can be difficult: “I live in the countryside, about half of an hour away from any town, or even any store. I would consider my home somewhat remote.” By choosing home birth, Cristin accepted certain risks. What if complications had arisen?

Cristin says, “Being that I live the distance that I do from any town, I also live that far from any hospital – and farther from any hospital that would be able to provide me the care I would need in the event of an emergency. I realized that had I truly needed medical care in the event of a serious complication, I may or may not have made it to the hospital in time enough for intervention. Having given birth in a hospital two times prior to my homebirth, I came to the conclusion that the unnecessary interventions I would face there were far more risky for myself and my baby than the small chance that I would need to transfer. I chose a very knowledgeable midwife who I trusted completely. I felt safe. It never crossed my mind that something negative might happen during my birth.”

rural populations above the national average – Alabama, Georgia, South Dakota, Iowa, Indiana, Michigan, and North Carolina. Several of the states have been working toward the goal of licensing midwives for a number of years. Despite the apparent benefits that licensing would have for families who choose homebirth and the midwives who serve them, some homebirth advocates do not favor licensing. A few states have chosen to forgo licensing in favor of laws that state that midwifery is not the practice of medicine and therefore falls outside of medical regulations. Maine, the most rural state in the nation according to the last census, is one of these states. “In 1978 the Attorney General issued an opinion that asserted that pregnancy and childbirth are part of normal, healthy human functioning and are therefore not covered by the Maine Medical Practice Act. As a result midwifery is not considered the practice of medicine in Maine and a medical license is not required to attend women in pregnancy and birth.” (Maine Association of Certified Professional Midwives)

To varying degrees the advocates who do not favor licensure agree that midwifery should be thought of as a traditional craft; they argue that it is in no way a practice of medicine nor is there need for regulation by a board. Those who take such a position usually hold that, instead, laws are needed that make midwifery legal and uphold a mother’s right to choose any caregiver she determines is best suited for her needs. They believe the only way to preserve the autonomy of a midwife’s practice, reduce the limitations on the women she can serve, and safeguard every woman’s right to give birth where and with whom she chooses, is to protect midwifery as a community tradition. The definitional issues, the beliefs underlying them and the legal ramifications are clearly complex.

Women who choose homebirth often emphasize that they are simply seeking reliable, loving, respectful, and evidence-based care. For some women a midwife’s credentials and/or licensing matter a great deal; others look more to the midwife’s personal experiences and her personality in deciding on the family’s birth attendant. But all women and men working within the growing homebirth movement believe in the safety of homebirth as well as a mother’s right to choose where and with whom she will give birth.

Women who choose homebirth are overwhelmingly proactive in their approach to maternity care and they also are typically self-educating, studying their options and the safety of their choices. For Jane Doe, the risks that she anticipated from homebirthing weren’t about her baby’s or her own physical safety, but about the judgment of others who look upon mainstream childbearing as safer.

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